The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

Summary

Summary

At 0712 on 18 June 2002, the Panama flag bulk carrier
Western Muse berthed at Port Kembla, NSW, to load a cargo
of steel slabs and coils for Pohang in South Korea. The vessel had
been chartered for the voyage by BHP Transport and Logistics.

The cargo was to be loaded using the ship's cranes. The master
was advised to ensure that the cranes and wires were in good
condition as they would be inspected by the stevedores before being
used. Before the vessel's arrival at Port Kembla, after checking
the cargo gear, both the master and mate were satisfied that the
cranes and wires were in good condition.

The stevedore's inspection of the cargo gear started soon after
the vessel had berthed, but unsuitable weather conditions led to
only one crane being checked that day. The next morning the other
cranes were inspected and, as a result, the mate was told to change
the cargo wire of no. 2 crane.

During the remainder of that day, the crew carried out the task
of changing the wire. Much of the work was carried out from the
platform on top of the crane, requiring the use of safety
belts.

By about 1745 the wire had been changed. The bosun, who was on
the platform on top of the crane, gave the order for the operation
of the crane to be checked. He then released the clip on the rope
lanyard attached to his safety belt from railing on the platform.
At the same time, the deck cadet, who had been operating the crane,
raised the cargo hook, then the jib.

The lanyard on the bosun's safety belt was drawn into the
sheaves for the jib, dragging the bosun in between the sheaves and
the luffing wire. He screamed out and one of two seamen with him
immediately shouted to the cadet, by handheld radio, to stop the
crane.

By the time the bosun was freed, he was haemorrhaging severely
from wounds to his leg and pelvis. The master asked for ambulance
assistance and, by about 1830, paramedics and a police rescue squad
were in attendance on the ship. Soon afterwards, one of the
paramedics advised the master that the bosun was dead.

The police forensic squad arrived to carry out their work and,
at about 2230, the bosun's body was removed from the top of the
crane and taken to the mortuary. The interim post-mortem report
stated that the cause of death of the bosun was massive traumatic
injuries resulting in amputation of the left leg and the side of
the pelvis.

The ATSB investigation concludes that, among other factors
contributing to the incident:

The task of changing the wire was physically and mentally
demanding, possibly causing the bosun's concentration to lapse at
the end of the day;

It is probable that the bosun was concentrating on the cargo
wire and that he was not watching the luffing wire after he
released the lanyard on his safety belt. In addition, poor light
would have made it difficult to see any detail on the
platform.

This report recommends that:

In accordance with the objectives of the ISM Code, companies,
in addition to documenting preventive maintenance procedures, also
develop, document and implement associated safety procedures;

Procedures and precautions for personnel working aloft include
warnings that loose clothing or personal safety equipment might
become entangled in moving machinery.

Conclusions

These conclusions identify the different factors contributing to
the incident and should not be read as apportioning blame or
liability to any particular individual or organisation.

Based on the evidence available, the incident occurred due to a
combination of the following factors:

After the bosun released the rope lanyard on his safety belt,
the lanyard became entangled in the luffing wire or was drawn into
the sheaves for that wire, dragging him in between the sheaves and
the wire.

The task of changing the cargo wire, in addition to being
arduous and lengthy, was physically and mentally demanding,
possibly causing the bosun's concentration to lapse at the end of
the day.

The conditions of lighting under which the crew were operating
at the top of the crane would have made it difficult to see any
detail on the platform.

It is likely that the bosun was concentrating on the movement
of the cargo wire and that he omitted to watch for movement of the
luffing wire.

Though the mate had signed a permit to work that morning, the
conditions for the permit were not re-assessed once darkness had
fallen.

While the company and the ship had the necessary ISM
accreditation, the safety manual contained no precautions or
procedures for the crew when working in close proximity to moving
machinery on cranes.

In addition, although not a contributing factor, the Inspector
concludes that the condition of the wire that was renewed did not
meet the requirements of Marine Orders Part 32. The wire was not
fit for use and, hence, did require replacing.